Improving psychotropic drug prescription in nursing home patients with dementia: design of a cluster randomized controlled trial

Medication review and deprescribing in different healthcare settings: a position statement from an Italian scientific consortium

Recent medical advancements have increased life expectancy, leading to a surge in patients affected by multiple chronic diseases and consequent polypharmacy, especially among older adults. This scenario increases the risk of drug interactions and adverse drug reactions, highlighting the need for medication review and deprescribing to reduce inappropriate medications and optimize therapeutic regimens, with the ultimate goal to improving patients' health and quality of life. This position statement from the Italian Scientific Consortium on medication review and deprescribing aims to describe key elements, strategies, tools, timing, and healthcare professionals to be involved, for the implementation of medication review and deprescribing in different healthcare settings (i.e., primary care, hospital, long-term care facilities, and palliative care). Challenges and potential solutions for the implementation of medication review and deprescribing are also discussed.

Usability of an app-based clinical decision support system to monitor psychotropic drug prescribing appropriateness in dementia

BACKGROUND

Guidelines recommend reluctant psychotropic drug (PD) prescribing in nursing home residents with dementia and neuropsychiatric symptoms (NPS), as efficacy of PDs is limited, and side effects are common. Nevertheless, PDs are commonly prescribed to reduce NPS. A smartphone application that evaluates appropriateness of PD prescriptions and provides recommendations from the revised Dutch guideline on problem behaviour in dementia may promote guideline adherence and increase appropriate prescribing.

OBJECTIVE

This study aimed to assess user experiences, barriers and facilitators of the Dutch 'Psychotropic Drug Tool' smartphone application (PDT) in the context of appropriate prescribing of PDs to nursing home residents with dementia and NPS.

METHODS/DESIGN

The PDT was developed according to the recommendations of the Dutch guideline for treatment of NPS in people with dementia. Feedback provided during usability testing with two end-users was applied to improve the PDT before implementation in day-to-day practice. Sixty-three prescribers were asked to use the PDT at their own convenience for four months. User expectations and experiences were assessed at baseline and after four months with the System Usability Scale and the Assessment of Barriers and Facilitators for Implementation.

RESULTS

Expected usability (M = 72.59; SD = 11.84) was similar to experienced usability after four months (M = 69.13; SD = 16.48). Appreciation of the PDTs user-friendliness (on average 6.7 out of 10) and design (7.3) were moderately positive, in contrast to the global rating of the PDT (5.7). Perceived barriers for PDT use were time consumption and lack of integration with existing electronic systems. Perceived facilitators were ease of use and attractive lay out. For broader implementation, physicians suggested a change in direction of the PDT: start assessment of appropriateness based on the list of NPS instead of PD as primary input.

CONCLUSIONS

In this pragmatic prospective cohort study we found that the PDT was used by elderly care physicians, with mediocre user satisfaction. The PDT will be optimized based on user feedback regarding experienced usability, barriers and facilitators, after which broader implementation can be initialized. The Medical Ethics Review Board of the University Medical Center Groningen declared this is a non-WMO study (UMCG RR Number: 201800284).

Systematic review on barriers and facilitators of complex interventions for residents with dementia in long-term care

OBJECTIVES

Psychotropic drugs are frequently and sometimes inappropriately used for the treatment of neuropsychiatric symptoms of people with dementia, despite their limited efficacy and side effects. Interventions to address neuropsychiatric symptoms and psychotropic drug use are multifactorial and often multidisciplinary. Suboptimal implementation of these complex interventions often limits their effectiveness. This systematic review provides an overview of barriers and facilitators influencing the implementation of complex interventions targeting neuropsychiatric symptoms and psychotropic drug use in long-term care.

DESIGN

To identify relevant studies, the following electronic databases were searched between 28 May and 4 June: PubMed, Web of Science, PsycINFO, Cochrane, and CINAHL. Two reviewers systematically reviewed the literature, and the quality of the included studies was assessed using the Critical Appraisal Skills Programme qualitative checklist. The frequency of barriers and facilitators was addressed, followed by deductive thematic analysis describing their positive of negative influence. The Consolidated Framework for Implementation Research guided data synthesis.

RESULTS

Fifteen studies were included, using mostly a combination of intervention types and care programs, as well as different implementation strategies. Key factors to successful implementation included strong leadership and support of champions. Also, communication and coordination between disciplines, management support, sufficient resources, and culture (e.g. openness to change) influenced implementation positively. Barriers related mostly to unstable organizations, such as renovations to facility, changes toward self-directed teams, high staff turnover, and perceived work and time pressures.

CONCLUSIONS

Implementation is complex and needs to be tailored to the specific needs and characteristics of the organization in question. Champions should be carefully chosen, and the application of learned actions and knowledge into practice is expected to further improve implementation.

Implementing a multidisciplinary psychotropic medication review among nursing home residents with dementia: a process evaluation

OBJECTIVES

Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569).

DESIGN

Process evaluation with multiple measurements.

SETTING

Thirteen units for people with dementia in six long-term care organizations in the Netherlands.

PARTICIPANTS

Physicians, pharmacists, and nursing staff of participating units.

INTERVENTION

The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance.

MEASUREMENTS

Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms.

RESULTS

Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention's relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator.

CONCLUSION

Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use.

Can the PROPER intervention reduce psychotropic drug prescription in nursing home residents with dementia? Results of a cluster-randomized controlled trial

OBJECTIVES

To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms.

DESIGN

A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months.

SETTING

Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands.

PARTICIPANTS

Three hundred eighty nursing home residents with dementia.

INTERVENTION

The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation.

MEASUREMENTS

Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms.

RESULTS

The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6 months (p = 0.01). Effects for the individual drug groups were minor (differences of 1.6 percentage points and below per 6 months) and not statistically significant. The occurrence of neuropsychiatric symptoms remained stable in both the intervention and control groups during the follow-up of 18 months.

CONCLUSIONS

The PROPER intervention failed to demonstrate effectiveness in reducing the prevalence of psychotropic drugs. It may be interesting to enrich the intervention with components that address personal attitudes and communication between nursing home professionals, not only with respect to the prescription of psychotropic drugs, but also to neuropsychiatric symptoms.The study has been registered in The Netherlands Trial Register (NTR3569).

Study of pharmacist intervention in polypharmacy among older patients: Non-randomized, controlled trial

AIM

We investigated the outcomes of interdisciplinary drug therapy interventions by pharmacists among older residents of special elderly nursing homes.

METHODS

The study was designed as a non-randomized, parallel-group, controlled study. Four nursing homes were allocated in a 1:1 ratio to an intervention group (IG) or control group (CG). The participants of the study were residents taking five or more medications. The nursing homes in the IG were each visited by one pharmacist, who was charged with looking for potential problems in drug therapy. Activities in the CG were carried out as usual. The intervention period was 6 months. The primary end-points were the incidences of potentially inappropriate medication (PIM) and falls. The mean difference and proportion of participants were compared between groups.

RESULTS

Data from 28 participants in the IG and 27 participants in the CG were analyzed. The number of PIM decreased from 2.64 at baseline to 2.39 after 6 months in the IG (P = 0.032). The proportion of participants in whom the use of PIM was reduced without problems was 17.9% in the IG and 3.7% in the CG (P = 0.094). The mean number of falls was 0.04 in the IG and 0.41 in the CG (P = 0.033). Falls occurred in 3.6% of participants in the IG and 22.2% of participants in the CG (P = 0.043).

CONCLUSIONS

The results suggested a trend toward fewer PIM and falls in the IG. Geriatr Gerontol Int 2019; ••: ••-••.

Reducing inappropriate psychotropic drug use in nursing home residents with dementia: protocol for participatory action research in a stepped-wedge cluster randomized trial

BACKGROUND

Psychotropic drugs are often prescribed to treat neuropsychiatric symptoms in nursing home residents with dementia, despite having limited efficacy and considerable side effects. To reduce the inappropriate prescribing of these psychotropic drugs, various non-pharmacological, psychosocial, person-centered, or multidisciplinary interventions are advocated. However, existing multidisciplinary interventions have shown variable effects, with limited effectiveness often resulting from suboptimal implementation. We hypothesize that an effective intervention needs to fit the local situation of a nursing home and that support should be offered during implementation.

METHODS

We will embed participatory action research within a stepped-wedge cluster randomized controlled trial to study the effects of a tailored intervention and implementation plan to reduce inappropriate psychotropic drug prescribing. Nursing homes will be provided with tailored information about the perceived problems of managing neuropsychiatric symptoms and we will offer coaching support throughout. Alongside the participatory action research, we will perform a process evaluation to examine the quality of the study, the intervention, and the implementation. Our aim is to recruit 600 residents from 16 nursing homes throughout the Netherlands, with measurements taken at baseline, 8 months, and 16 months. Nursing homes will be randomly allocated to an intervention or a deferred intervention group. During each intervention stage, we will provide information about inappropriate psychotropic drug prescribing, neuropsychiatric symptoms, and difficulties in managing neuropsychiatric symptoms through collaboration with each nursing home. After this, a tailored intervention and implementation plan will be written and implemented, guided by a coach. The primary outcome will be the reduction of inappropriate prescribing, as measured by the Appropriate Psychotropic drug use In Dementia index. Secondary outcomes will be the frequency of psychotropic drug use and neuropsychiatric symptoms, plus quality of life. A mixed methods design will be used for the process evaluation. Effects will be assessed using multilevel analyses. The project leader of the nursing home and the coach will complete questionnaires and in-depth interviews.

DISCUSSION

We anticipate that the proposed tailored intervention with coaching will reduce inappropriate psychotropic drug prescribing for nursing home residents with neuropsychiatric symptoms. This study should also provide insights into the barriers to, and facilitators of, implementation.

TRIAL REGISTRATION

NTR5872 , registered on July 2, 2016.

Consensus and evidence-based medication review to optimize and potentially reduce psychotropic drug prescription in institutionalized dementia patients

Background

Dementia patients often show neuropsychiatric symptoms, known as behavioral and psychological symptoms of dementia (BPSD). These are a common motive for medical consultations, hospitalizations, and nursing home stays. Various studies have suggested that the high prevalence of psychotropic drug use to treat BPSD in institutionalized dementia patients may lead to impaired cognitive capacity, rigidity, somnolence, and other complications during the course of the illness. The aim of this study was to design a consensus-based intervention between care levels to optimize and potentially reduce prescription of psychotropic drugs in institutionalized patients with dementia and assess the changes occurring following its implementation.

Methods

Design: Prospective, quasi-experimental, pre/post intervention, multicenter study. Scope: 7 nursing homes associated with a single primary care team. Inclusion Criteria: Institutionalized patients diagnosed with dementia and under treatment with 1 or more psychotropic drugs for at least 3 months. Sample: 240 individuals; mean age, 87 years (SD: 6.795); 75% (180) women. Intervention: Creation of evidence-based therapeutic guidelines for psychotropic drug use in the treatment of BPSD by consensus between reference professionals. Joint review (primary care and geriatric care nursing home professionals) of the medication based on the guidelines and focusing on individual patient needs. Primary variable: Number of psychotropic drugs used per patient. Assessment: Preintervention, immediate postintervention, and at 1 and 6 months.

Results

Overall, the number of psychotropic drugs prescribed was reduced by 28% (from 636 before to 458 after the intervention). The mean number of psychotropic drugs prescribed per patient decreased from 2.71 at baseline to 1.95 at 1 month postintervention and 2.01 at 6 months (p < 0.001 for both time points). Antipsychotics were the drug class showing the highest reduction rate (49.66%). Reintroduction of discontinued psychotropic drugs was 2% at 1 month following the intervention and 12% at 6 months.

Conclusions

A consensus guidelines-based therapeutic intervention with a patient-centered medication review by a multidisciplinary team led to a reduction in prescription of psychotropic drugs in institutionalized dementia patients.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-1015-9) contains supplementary material, which is available to authorized users.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

The effect of biannual medication reviews on the appropriateness of psychotropic drug use for neuropsychiatric symptoms in patients with dementia: a randomised controlled trial

Objective

We studied the efficacy of biannual structured medication reviews to improve the appropriateness of psychotropic drug (PD) prescriptions for neuropsychiatric symptoms (NPS) in nursing home patients with dementia.

Study Design and Setting

In this randomised controlled trial, the intervention encompassed a structured multidisciplinary medication review by physician, pharmacist and nurse. During this 18-month study, the patient's medical files were assessed every 6 months. The primary outcome was the appropriateness of PD prescriptions defined by the Appropriate Psychotropic drug use In Dementia (APID) index sum score, lower scores indicating more appropriate use.

Results

At baseline, 380 patients were included, of which 222 were randomised to the intervention group. Compared to the control group, the APID index sum score in the intervention group improved significantly for all PD prescriptions (-5.28, P = 0.005).

Conclusion

We advise the implementation of a structured, repeated medication review with the essential roles of pharmacist, physician and nurse, into daily practice. This work was supported and funded by the Netherlands Organisation for Health Research and Development (ZonMw). Netherlands Trial Register (NTR3569).

An Ecological Framework to Support Small-Scale Shared Housing for Persons with Neurocognitive Disorders of the Alzheimer's and Related Types: A Literature Review

BACKGROUND

Small scale shared housing arrangements (SHAs) is a deinstitutionalized model of care designed to resemble a typical home of <10 people and are increasingly available for persons with neurocognitive disorders of the Alzheimer's and related types (NCD). However, there is little aggregate evidence of their effect on persons with NCD thus, a literature review was performed.

METHODS

Database searches were conducted across CINAHL Complete, OTseeker, PubMed, Ovid, Academic One File, ProQuest Nursing and Allied Health, the World Wide Web and Google Scholar using the several key words that included neurocognitive disorders, Alzheimer's, dementia, quality of life, well-being, occupational performance, activities of daily living, small scale shared housing, sheltered housing and group homes. Bibliographic references from final articles were also examined. Selection criteria involved three steps: screening perspective articles by title and abstract, assessing full text for eligibility and finally, reviewing full-texts.

RESULTS

16 studies were selected for final review where most found the association of SHAs with various occupational performance indicators unique to the NCD population better than or equal to controls (traditional models of long term care). A small minority of studies had mixed or inconclusive results. No study found SHAs necessarily worse than controls.

CONCLUSION

The SHA model has many benefits for person's with NCD and may be especially advantageous for those in the early stages of the disease process. The occupational therapy profession should continue to raise awareness of SHAs and consider ecological theory as a valid basis for their expansion.

[Reinforced accommodation units and the management of patients with dementia]

Dementia is frequently associated with behavioural disorders that can be difficult to manage. In regards to these symptoms, psychoactive drugs are not very effective and have many potential side effects. In order to take care of patients with such severe disorders, specific units called "reinforced hosting units" ("UHR; Unités d'Hébergement Renforcées" in French) have been developed within long term care units. Specifically trained teams take care of these patients in specially designed settings. A French national inquiry has studied the development, the characteristics and the activity of these units in 2013 and 2012.

Role of community pharmacists in the use of antipsychotics for behavioural and psychological symptoms of dementia (BPSD): a qualitative study

OBJECTIVE

This study aimed to use qualitative methodology to understand the current role of community pharmacists in limiting the use of antipsychotics prescribed inappropriately for behavioural and psychological symptoms of dementia.

DESIGN

A qualitative study employing focus groups was conducted. Data were analysed using thematic analysis.

SETTING

3 different geographical locations in the England.

PARTICIPANTS

Community pharmacists (n=22).

RESULTS

The focus groups identified an array of factors and constraints, which affect the ability of community pharmacists to contribute to initiatives to limit the use of antipsychotics. 3 key themes were revealed: (1) politics and the medical hierarchy, which created communication barriers; (2) how resources and remit impact the effectiveness of community pharmacy; and (3) understanding the nature of the treatment of dementia.

CONCLUSIONS

Our findings suggest that an improvement in communication between community pharmacists and healthcare professionals, especially general practitioners (GPs) must occur in order for community pharmacists to assist in limiting the use of antipsychotics in people with dementia. Additionally, extra training in working with people with dementia is required. Thus, an intervention which involves appropriately trained pharmacists working in collaboration with GPs and other caregivers is required. Overall, within the current environment, community pharmacists question the extent to which they can contribute in helping to reduce the prescription of antipsychotics.

Trajectories of Neuropsychiatric Symptoms and Cognitive Decline in Mild Cognitive Impairment

OBJECTIVE

To characterize the course of neuropsychiatric symptoms (NPS) in adults with mild cognitive impairment (MCI), and to examine baseline individual-level predictors and associated cognitive and functional outcomes.

DESIGN

A 2-year prospective cohort study.

SETTING

Multicenter clinical settings.

PARTICIPANTS

Five hundred sixty individuals with MCI at baseline.

MEASUREMENTS

NPS severity (measured using Neuropsychiatric Inventory Questionnaire) and cognitive and functional outcomes were assessed at baseline and every 6 months thereafter. Potential individual-level predictors were collected at baseline.

RESULTS

Three latent classes of NPS courses were identified using growth mixture modeling: a stable class in which a low NPS burden remained relatively unchanged over time (N = 503, 89.8%); a worsened class in which an initially moderate NPS burden increased (N = 39, 7.0%); and an improved class in which an initially high NPS burden decreased (N = 18, 3.2%). There were no associations between class membership and baseline individual characteristics. Members of the worsened class were 1.74 times more likely to be diagnosed with incident Alzheimer disease (AD) than members of the stable class (95% confidence interval: 1.07-2.84). The worsened class also showed significantly more rapid declines in cognitive and functional outcomes than the stable class. Class membership did not predict rate of brain atrophy.

CONCLUSIONS

Patients with MCI may experience different trajectories of NPS over time. Patients with worsening NPS may be at greater risk of developing AD and severe cognitive and functional impairment.

The development and testing of the quality use of medications in dementia (QUM-D): a tool for quality prescribing for behavioral and psychological symptoms of dementia (BPSD)

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are virtually ubiquitous in dementia. Excessive recourse to use of psychotropics which have high risk to benefit ratio remains a global problem. We aimed to identify components of quality prescribing in BPSD to develop a tool for quality prescribing and to test this tool.

METHODS

We used Delphi methodology to identify elements of quality prescribing in BPSD. The tool was tested by a range of medical and nursing professionals on 48 patients, in inpatient and ambulatory settings in Northern Sydney Local Health District, Australia.

RESULTS

Consensual opinion using Delphi method was that quality prescribing in dementia comprised ten factors including failure to use first line non-pharmacological strategies, indication, choice of drug, consent, dosage, mode of administration, titration, polypharmacy, toxicity, and review. These elements formed the quality use of medications in dementia (QUM-D) tool, lower scores of which reflected quality prescribing, with a possible range of scores from 0 to 30. When inter-rater reliability was tested on a subgroup of raters, QUM-D showed high inter-rater reliability. A significant reduction in QUM-D scores was demonstrated from baseline to follow-up, mean difference being 5.3 (SD = 3.8; 95% confidence interval 4.1-6.4; t = 9.5; df = 47; p < 0.001). There was also a significant reduction in score from baseline to follow-up when rated by clinical nurse consultants from a specialized behavior assessment management service (BAMS) (N = 12).

CONCLUSION

The QUM-D is a tool which may help to improve quality prescribing practices in the context of BPSD. In this setting, we consider quality prescribing, and accordingly the obligations of prescribers, to be an inclusive concept rather than just adding to the mantra of "not prescribing."

PROPER I: frequency and appropriateness of psychotropic drugs use in nursing home patients and its associations: a study protocol

BACKGROUND

Nursing home patients with dementia use psychotropic drugs longer and more frequently than recommended by guidelines implying psychotropic drugs are not always prescribed appropriately. These drugs can have many side effects and effectiveness is limited. Psychotropic drug use between nursing home units varies and is not solely related to the severity of neuropsychiatric symptoms. There is growing evidence indicating that psychotropic drug use is associated with environmental factors, suggesting that the prescription of psychotropic drugs is not only related to (objective) patient factors. However, other factors related to the patient, elderly care physician, nurse and the physical environment are only partially identified. Using a mixed method of qualitative and quantitative research, this study aims to understand the nature of psychotropic drug use and its underlying factors by identifying: 1) frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms in nursing home patients with dementia, 2) factors associated with (appropriateness of) psychotropic drug use.

METHODS

A cross-sectional mixed methods study. For the quantitative study, patients with dementia (n = 540), nursing staff and elderly care physicians of 36 Dementia Special Care Units of 12 nursing homes throughout the Netherlands will be recruited. Six nursing homes with high average rates and six with low average rates of psychotropic drug use, based on a national survey about frequency of psychotropic drug use on units, will be included. Psychotropic drugs include antipsychotics, anxiolytics, hypnotics, antidepressants, anticonvulsants and anti-dementia drugs. Appropriateness will be measured by an instrument based on the Medication Appropriateness Index and current guidelines for treatment of neuropsychiatric symptoms. Factors associated to psychotropic drug use, related to the patient, elderly care physician, nurse and physical environment, will be explored using multilevel regression analyses. For the qualitative study, in depth interviews with staff will be held and analyzed to identify and explore other unknown factors.

DISCUSSION

This study will provide insight into factors that are associated with the frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms. Understanding psychotropic drug use and its associations may contribute to better dementia care.